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Miscellaneous thoughts and ramblings
Wednesday, June 15, 2005
Schiavo's Autopsy Results Released
Terry Schiavo's tragic case generated many posts and many comments at the Coffeehouse. (Most of it is here if you weren't a Coffeehouse regular at the time.) Her autopsy results help answer some of the questions surrounding her case.
Terri Schiavo (search) died from dehydration and was not abused before her 1990 collapse, an autopsy report revealed Wednesday.

The report also showed there was no evidence Schiavo was given harmful drugs or other substances before her death.
"There's nothing in her autopsy report that is inconsistent with a persistent vegetative state," said Dr. Stephen J. Nelson, a medical examiner who assisted in the autopsy.

Thogmartin also said Schiavo was blind, her brain was half its normal size and she was suffering from severe osteoporosis at the time of death.

"The brain weighed 615 grams, roughly half of the expected weight of a human brain. ... This damage was irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons."
Too bad you guys cited FOX news for all of the information. Or maybe I'm missing something.
Andrew: It's the same information available everywhere. I heard it on the network news at 9:00.
it will be interesting to see how the blogs digest this on both the right and left.
Andrew: Here is the AP story via Yahoo. I like FoxNews, but in any case, I don't understand your objection. Fox is frequently criticized for being too conservative, but the story I'm showing would tend to argue against the conservative position on this case. Maybe you are missing something. Or maybe I am.

ball-and-chain: Just remember, I want my feeding tube pulled the second my brains weighs less than 700 gm (which at this rate should be next week).

Dr. Charles: Just to put my cards on the table: I'm a crazy-right-winger on almost every issue. Nomad (a fellow conservative and a friend of mine for more than half my life) and I disagreed frequently about Ms. Schiavo's case. I really think that the Republican Senate (esp. Tom Delay) and the White House acted terribly on this, and I'm very disappointed in them.
At first I thought Andrew meant that the many posts and comments on this subject at the Coffeehouse in the past were somehow based on Fox news reports, with the implication that the posts & comments were not consistent with Andrew's position and therefore foolish. But as Bean points out, there were comments both pro and con on this issue 'round here, so indeed I don't know what he's talking about.

But I am so tired of people using Fox news as a bogeyman. I rarely watch Fox news or go to their website, and I'm still pretty much a reactionary right-wing nutjob.

And, finally, I see how these results could speak to someone who truly thought Terri could have been rehabilitated, but not for those who thought she just had some loving family members who were happy to care for her.
None of this answers the question that bothers ME the most: how did she end up in PVS?
I got owned here.
I wrote plenty about this, but I am not going to rehash it other than to say that I never believed that she was really responding.

It was just the body responding to stimuli.

In any case my heart does go out to her family and loved ones for having to endure a private moment on the public stage.
Andrew - we fogies don't understand your lingo.
Toby Katz on Cross-Currents has a post that resonated with me.
Ralphie: “I see how these results could speak to someone who truly thought Terri could have been rehabilitated, but not for those who thought she just had some loving family members who were happy to care for her.”

But it was a main argument of the parents that she could be rehabilitated. The husband was happy to care for her. She did not lack for people willing to care for her. She was not allowed to die because no one wanted to care for her. She was allowed to die because the husband believed that she would not want to live in her current condition. The parents then tried to raise multiple questions about that condition and about its permanence. Those questions have now been answered.

Irina: The autopsy doesn’t answer that question, but does not lend any evidence to the parents’ multiple accusations that she was abused.

Jack: Yup. The videos showing her eyes moving around that were so widely publicized (and I’m embarrassed to say fooled Republican Senators who had no business in the case) were billed as evidence that she was looking at a relative or at a balloon. The many minutes of video showing her looking at nothing weren’t shown. Now we know that she had no occipital cortex, the brain responsible for sight. So she was blind. It’s a good lesson about the very strong power of love and wishful thinking to bias what we see.

Andrew: I don’t understand.

Ralphie: Katz’s post helps clarify why I (a religious Jew, in case we have new readers) don’t follow Jewish medical ethics. He at least makes it clear that the religious Jewish position has nothing to do with her medical condition. Meaning, he accepts that she was in PVS and would never improve. This is the problem with Jewish law on medical ethics. It does not recognize a patient’s right to refuse care. It also makes a distinction between not starting certain treatments (like ventilators or feeding tubes) which is sometimes permissible, and withdrawing those treatments which is generally not permissible. Secular medical ethics makes no such distinction; withdrawing or not starting a treatment are considered similar acts. If adopted broadly, Jewish medical ethics would create a completely unworkable system. If a patient in such a system would not want tube feedings if ever in a state similar to Ms. Schiavo’s, such a patient would have to make it clear that he would not want the tube inserted in the first place, since once inserted, it could not be removed. If a patient would not want to spend years on a ventilator, and had an acute breathing problem that could be fixed in a few days, he would be in the terrible position of having to decide “Do I accept the ventilator now, hoping that in a few days I recover, or do I refuse the ventilator, since once I’m on it, I can’t insist that it be removed?”

That Katz uses the phrase “murder brain-damaged people” rather than “allow to die” also reveals a confusion about basic ethical principles. Giving someone poison with the intention of killing her is murder. Schiavo was not murdered. Having a patient with a life-threatening pneumonia refuse antibiotics is not suicide, and the doctor who obeys his wishes is not a murderer. The pneumonia is simply allowed to progress and the patient is allowed to die. Ms. Shiavo’s brain damage would have killed her long ago without the feeding tube. Removal of her feeding tube allowed this to occur.

Secular medical ethics never removes the patient’s right to refuse care. In doing that, I believe that it recognizes and sanctifies Schiavo’s soul far more than Jewish medical ethics.
She wasn't able to survive on her own. She had no capacity to communicate with anyone. No ability to interact and no hope of recovery. There comes a point in time at which keeping someone's body alive is no longer humane but cruel.
It was always clear to me that Terri Schiavo's parents were deluded when they thought her condition might miraculously improve. So the autopsy tells me nothing I didn't already know.

I spent six years working with developmentally challenged individuals, some of whom were no higher-functioning than Terri Schiavo. It was our conviction that they were still fully human beings, and their lives were still worth living.

I understand your point about the right to refuse treatment, Dr. Bean. But we're talking about making a decision while you're still healthy about how you would feel if your condition changed for the worse. That, to me, is a questionable proposition.

How many of us, when we were young, were horrified at the prospect of being old and relatively infirm? And yet, as we age, we realize it isn't as miserable an experience as we imagined, and life is still very much worth living.

Terri Schiavo didn't appear to be suffering. I don't know what harm would have been done by allowing her to continue living. I think the husband should have stepped aside and allowed her parents to care for her as they saw fit.

On the other hand, I agree with you about the politicians. They should not have attempted to interfere with the courts' determination of the issue.
Ralphie, since you are a religious Jew I'm surprised you didn't recognize "Toby" as a woman's name. It's really Yiddish, Toiba, which means "dove." So bottom line, I am a she and not a he.

Jewish law makes a distinction between withholding food and water--without which NO ONE can survive--and withholding antibiotics or other medicines. A patient does have the right to refuse medical care--for example, to refuse surgery or to refuse chemotherapy. A patient can refuse something that if he were well, he would not need. And his relatives can refuse medical care on his behalf.

He can even refuse to eat if he's awake and competent. However, no one else is allowed to withhold food and water from a patient. That's because food and water are not considered medicine, but just what every person needs in order to survive.

If you withheld food and water from someone who was too weak to get it himself--if you refused to feed an unwanted infant, for example--Jewish law would consider that murder.

Other forms of life support, like a respirator, are trickier and questions need to be asked of competent rabbinical authorities on a case by case basis.

Rabbi Dr. Moshe Tendler is one who has written extensively on questions of medical ethics and halacha. My Cross-Currents post was by no means meant to be used as an exhaustive halachic guide but only to give a rough idea of the way Judaism looks at these issues.

But to reiterate, it is not permissible to withhold food and water under Jewish law. And in the case of someone who needs no medical care at all but just needs to be fed and cleaned up, like Terri Schiavo, refusing to feed her was simply unconscionable. She was not able to swallow but she was able to digest food and could have lived for years.
Oh, one other thing I meant to say: I doubt that Terri's parents seriously thought there was any hope of recovery, but that seems to have been the only argument available under the law that would allow her to live.
Jack: I agree.

Q: I salute you for your admirable work and for your dedication to treating all people with the dignity they deserve. I also agree with you that decisions made when people are healthy are frequently reconsidered as their health changes. There have been studies in which healthy people were described various states of health and asked which of these states, if any, were worse than death. Later, some of those people found themselves in states similar to the ones they were asked about. Many changed their minds and decided they would rather live. So your point is a good one that ultimately it's hard to know what a non-communicative person would want.

Ms. Katz: First of all, welcome to our Coffeehouse! Second, it was me (Doctor Bean), not Ralphie, that mistook you for a guy. I apologize for that. (You don't know religious Jews who don't know Yiddish? Oy! I feel like a complete shmegegi.) What you say about withholding food and water is precisely the same in secular medical ethics as well. That is, even if a patient is imminently dying and is refusing medical care, she must be brought food. Secular medical ethics, however, distinguishes tube feedings from oral food. Tube feedings are considered a (artificial) medical therapy which may be refused and withheld, while oral food may not. Ms. Schiavo's brain damage left her unable to swallow. That's a fatal problem which would not be remedied by the provision of oral food. That's what killed Ms. Schiavo.

As to your suggestion that Ms. Schiavo's parents were realistic about her condition but used false optimism as a legal ploy, what evidence is there of that? They made their claims of her condition being reversible not just in court but to the media. What makes you think that they didn't believe what they said? Did you think that before the autopsy results were available?
Hmmm - if the only difference between secualr ethics and Jewish ethics is oral feeding vs. tube feeding, I'm gonna have to go with Jewish ethics. To be fair, as a guy who tries his best to follow halacha, I would have gone with it anyway.

It seems to me, according to Ms. Katz' comments, that the patient has more power than the doctor in Jewish ethics. That is, if the doctor is not allowed to mandate cessation of oral feeding to the patient but the patient can refuse food. (Seems a little odd considering suicide is a definite no-no, so maybe I'm not understanding something here completely.)

Bean: I was going to try to put this sensitively, but then I remembered I am an insensitive lout: why does secular medical ethics get promoted over Jewish ethics, but not other types of secular ethics or even lack thereof?
Oh, and Ms. Katz - I knew you were female from pronouns used on Cross-Currents. And from the fact that you teach at Bais Ya'akov. Maybe there are male teachers there and I assumed, but then I assumed correctly. But I admit I didn't think about the "Toby" part...
Ralphie: "if the only difference between secualr ethics and Jewish ethics..." No. There are other differences, like the distinction between not starting a therapy and withdrawing it, which does not exist in secular medical ethics.

Can you restate your question? I don't get what you mean.
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